Revision Total Knee Arthroplasty With an Imageless, Second-Generation Robotic System.

BACKGROUND: Robotic-assisted total knee arthroplasty is increasingly used in revision total knee arthroplasty (rTKA), with imageless systems recently receiving Food and Drug Administration (FDA) approval. However, there remains a paucity of literature on the use of robotic assistance in revision total knee arthroplasty (TKA). This paper describes the imageless surgical technique for robotic revision TKA using a second-generation robotic system and details both intraoperative and 90-day outcomes. METHODS: This was a retrospective review of 115 robotic revision TKAs from March 2021 to May 2023 at 3 tertiary academic centers. Patient demographics, perioperative surgical data, and 90-day outcomes were collected. Pain and Patient-Reported Outcomes Measurement Information System scores preoperatively and postoperatively were recorded. All-cause reoperations at the final follow-up were detailed. The mean patient age was 65 years (range, 43 to 88), and 58% were women. The mean follow-up time was 13 months (range, 3 to 51). RESULTS: The most common indications for rTKA were instability (n = 37, 32%) and aseptic loosening (n = 42, 37%). There were 83 rTKAs to a posterior-stabilized liner, 22 to a varus-valgus constrained liner, and 5 to a hinged construct. The median polyethylene size was 11 (interquartile range, 10 to 13), and 93% of patients had their joint line restored within 5 millimeters of the native contralateral knee. Within the 90-day postoperative window, there were 8 emergency department visits and 2 readmissions. At the final follow-up, there were 5 reoperations and 2 manipulations under anesthesia. There were 4 patients who required irrigation and debridement after superficial wound dehiscence, and one had an arthrotomy disruption after a fall. CONCLUSIONS: This review demonstrates favorable intraoperative and 90-day outcomes and suggests that imageless robotic surgery is a promising modality in rTKA. Further studies comparing the longitudinal outcomes after robotic and conventional rTKA are warranted.

Periarticular Injection With or Without Adductor Canal Block for Pain Control Following Total Knee Arthroplasty.

INTRODUCTION: Periarticular injections (PAIs) have become a critical part of multimodal anesthetic regimens for total knee arthroplasty (TKA). This study assessed the effect of adductor canal blocks (ACBs) alone, periarticular injections (PAIs) alone, and the combination of both ACBs and PAIs on postoperative pain management in patients undergoing primary TKA. We hypothesized that there would be no significant difference in postoperative outcomes, including pain scores and narcotic use. METHODS: Patients who underwent primary TKA were retrospectively identified from February 2022 to February 2023. Patients were stratified based on perioperative local/regional anesthetic regimen (PAI only, PAI with an ACB, and ACB only) and matched in a 1:1:1 ratio. Patients were propensity score matched based on age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and preoperative narcotic usage. Patient demographics, as well as intra- and postoperative variables including narcotic refills, postoperative morphine requirements, pain scores, and readmissions, were compared. After successful matching, there were 40 patients in each cohort. RESULTS: First post-anesthesia care unit (PACU) visual analog pain scale (VAS) scores after surgery were not significantly different across all groups (P = 0.082). Pair-wise comparisons of patients receiving either PAI alone or ACB alone showed that patients receiving PAIs had lower narcotic usage at six hours (P = 0.037). A PAI alone also demonstrated a shorter length of stay compared to ACB alone (P = 0.001). Postoperative narcotics refills were similar between ACB only and PAI only (P = 0.056); however, PAI with an ACB had lower postoperative narcotic refills (P = 0.017). The rate of same-day physical therapy (PT) clearance was lowest in the ACB only group (37.5% [15 of 40]) (P = 0.002). CONCLUSION: As hypothesized, there was no difference in pain scores immediately after surgery; however, postoperative morphine requirements at six hours, same-day physical therapy clearance, and length of stay were better in the PAI group. The use of PAIs may confer a benefit for both patients and healthcare systems as an adjunct to perioperative pain control.

Outcomes after bilateral shoulder arthroplasty: a systematic review.

The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA). Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (["bilateral" OR "contralateral"] AND "shoulder" AND ["arthroplast∗" OR "replacement"]). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using Methodological Index for Nonrandomized Studies and Modified Coleman Methodology scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA) <20 months to IBA ≥20 months. Nineteen studies analyzed bilateral TSA (n = 3), bilateral RSA (n = 7), and TSA/RSA (n = 8). The mean Methodological Index for Nonrandomized Studies was 18 and mean Modified Coleman Methodology Score was 74, with 63.2% of studies demonstrating level III evidence. A total of 2729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0° vs. 129.6°), external rotation (ER) (42.5° vs. 25.6°), and internal rotation (60% reaching T12-T8 vs 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), American Shoulder and Elbow Surgeons (87.9 vs. 77.7), and Single Assessment Numeric Evaluation (SANE) (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater ER and patient satisfaction than patients with IBA <20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA. Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA but higher complication, reoperation, and revision rates. IBA ≥20 months is associated with greater ER and satisfaction than IBA <20 months.

Robotic Technology in Foot and Ankle Surgery: A Comprehensive Review.

Recent developments in robotic technologies in the field of orthopaedic surgery have largely been focused on higher volume arthroplasty procedures, with a paucity of attention paid to robotic potential for foot and ankle surgery. The aim of this paper is to summarize past and present developments foot and ankle robotics and describe outcomes associated with these interventions, with specific emphasis on the following topics: translational and preclinical utilization of robotics, deep learning and artificial intelligence modeling in foot and ankle, current applications for robotics in foot and ankle surgery, and therapeutic and orthotic-related utilizations of robotics related to the foot and ankle. Herein, we describe numerous recent robotic advancements across foot and ankle surgery, geared towards optimizing intra-operative performance, improving detection of foot and ankle pathology, understanding ankle kinematics, and rehabilitating post-surgically. Future research should work to incorporate robotics specifically into surgical procedures as other specialties within orthopaedics have done, and to further individualize machinery to patients, with the ultimate goal to improve perioperative and post-operative outcomes.

Trends in outcomes following aseptic revision shoulder arthroplasty.

PURPOSE: As the incidence of anatomic and reverse total shoulder arthroplasty (TSA, RSA) increases, revision procedures will also increase with a corresponding need for counseling patients regarding outcomes. We hypothesized that different revision categories would have different complication profiles depending on both the indication as well as the nature of the prior hardware. METHODS: A retrospective review of 1773 cases performed at a single tertiary health system utilized case postings and diagnoses to identify revision shoulder arthroplasty cases. Revisions were classified based on the prior hardware present, with basic demographics and other perioperative and postoperative outcomes recorded within the limits of available follow-up. RESULTS: 166 surgical cases involving revision of prior shoulder arthroplasty metal hardware were identified with an average follow-up of 1.0 years. Immediate perioperative outcomes of revision cases were similar relative to the companion cohort of 1607 primary cases. 137 cases (83%) required no further revision surgery, while 19 cases (11%) underwent aseptic revision, and 10 cases (6%) were revised for periprosthetic infection. RSA hardware revised to another RSA had the highest repeat revision rate relative to the other revision categories (32% vs < 14%). CONCLUSIONS: Revision of reverse shoulder arthroplasty to a repeat reverse has the highest rate of subsequent all-cause revision, and these repeat revisions often occurred for periprosthetic infection. Despite a relatively high long-term complication rate following revision shoulder arthroplasty, immediate perioperative outcomes remain similar to primary cases, providing some preliminary evidence for policymakers considering inclusion in future value-based care models. LEVEL OF EVIDENCE: Level III Treatment Study.

Gender Trends in Authorship in 6 Major Orthopaedic Journals.

BACKGROUND: Historically, orthopaedic surgery has had low female representation, with <6% of practicing surgeons identifying as female. Although prior literature has illustrated gender disparities in first and last authorship as well as changes in gender representation over time, less attention has been paid to middle authorship. We hypothesized that trends in female authorship would reflect increasing female participation in orthopaedic surgery and orthopaedic subspecialties coinciding with an overall increase in female authorship. METHODS: Bibliometric information from articles published between 2011 and 2021 in 6 orthopaedic journals was extracted with use of the Web of Science. Collected data included author order, author names, affiliation, and corresponding author address. A gender was assigned with the use of Genderize.io, which is validated software, on the basis of author first name. Statistical analysis was performed with use of an analysis of variance for each journal, and linear regression was performed to determine trends, controlling for year. RESULTS: Among all included orthopaedic journals, female middle authorship increased by 5 percentage points, female first authorship increased by 4 percentage points, and female last authorship increased by 1 percentage point. Over the study period, the highest rate of female middle authorship (28%) was seen in the Journal of Pediatric Orthopaedics, whereas the lowest rate (16%) was seen in The Journal of Arthroplasty . We found that the 5 highest-producing female last authors were, on average, cited significantly less per publication than their male counterparts in all but 2 journals. CONCLUSIONS: Gender gaps exist within orthopaedic surgery as well as within its body of literature. Although this study highlights areas of growth, it also promotes further inquiry into research productivity and the availability of opportunity within orthopaedic surgery as a whole. The increase in female middle authorship overall and in each journal demonstrates momentum for future growth for women in the field of orthopaedic surgery.

Risk Factors of Failure to Discharge Before "Two Midnights" in Outpatient-Designated Total Hip Arthroplasty.

INTRODUCTION: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days. METHODS: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days. RESULTS: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection (P < 0.01), hospital readmission (P < 0.01), and revision surgery (P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days. CONCLUSION: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

Modern Patellofemoral Arthroplasty.

INTRODUCTION: The ideal procedure for isolated patellofemoral arthritis is a controversial topic. Patellofemoral arthroplasty (PFA) is an option that aims to restore normal kinematics to the knee while preserving bone. PFA has been shown to have benefits compared with total knee arthroplasty (TKA) in this patient population but has historically had a high failure rate. Revision rates are improving with modern implants and tight indications but still remain higher than TKA. This review summarizes current thinking around PFA using modern implants and techniques in 2023, provides an implant-specific analysis, and assesses how we can improve outcomes after PFA based on the current literature. The aim was to provide an outline of the evidence around PFA on which surgeons can make decisions to optimize patient outcome in this young and active population. METHODS: Four databases (MEDLINE, Embase, Scopus, and SPORTDiscus) were searched for concepts of patellofemoral joint arthroplasty. After abstract and text review, a screening software was used to assess articles based on inclusion criteria for studies describing indications, outcomes, and techniques for isolated PFA using modern implants, with or without concomitant procedures. RESULTS: A total of 191 articles were included for further examination, with 62 articles being instructional course lectures, systematic reviews, technique articles, narrative reviews, expert opinions, or meta-analyses. The remaining articles were case reports, trials, or cohort studies. Articles were used to create a thorough outline of multiple recurrent topics in the literature. CONCLUSIONS: PFA is an appealing option that has the potential to provide a more natural feeling and functioning knee for those with isolated PF arthritis. The high rate of revision is a cause for concern and there are several technical details that should be stressed to optimize results. The uncertain outcome after revision to TKA also requires more investigation. In addition, the importance of strict selection criteria and firm indications cannot be stressed enough to optimize longevity and attempt to predict those who are likely to have progression of tibiofemoral osteoarthritis. The development of new third-generation implants is promising with excellent functional outcomes and a much lower rate of maltracking and implant complications compared with earlier generations. The impact of these implants and improvement in surgical techniques on the revision rate of PFA will be determined from longer-term outcomes.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty.

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Biomechanical profile of varying suture button constructs in cadaveric specimens: a systematic review and meta-analysis.

Background: Suture button fixation of syndesmotic injuries allows for more physiologic motion of the ankle joint while maintaining adequate reduction and may avoid the need for additional surgeries, given the lower risk of syndesmotic diastasis and implant failure. Few studies have examined the optimal number and configuration of suture buttons for syndesmotic disruption. The purpose of this systematic review and meta-analysis is to compare different suture button configurations from the cadaveric literature and to assess their relative effect on the stability of the syndesmotic reduction and functional movement of the ankle. Methods: A literature search in the databases MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, and SPORTDiscus via EBSCO were searched through December 2022 to identify studies related to cadaveric modeling of the syndesmosis. Only cadaveric studies with suture button fixation and studies in English were included. The quality of cadaveric studies was assessed using the Quality Assessment for Cadaveric Studies (QUACS) tool. Revman 5.3 software was used to perform the meta-analysis. Results: The meta-analysis included 5 studies and 86 limbs. The systematic review included 15 studies. When comparing single and double suture button configurations, no difference was found between groups with regard to fibular rotation (MD =-0.9; 95% CI: -2.09 to 0.27; I2=79%; P=0.13) and both groups had similar rotational stability. The double suture button technique did demonstrate less sagittal fibular translation compared to the single suture button (MD =0.48; 95% CI: 0.02-0.94; I2=66%; P=0.04). When comparing two suture buttons in parallel and divergent configurations, studies did not find any differences with regard to strength or stability. Conclusions: There were no significant differences in biomechanical parameters when comparing single and double suture button constructs. While single button suture constructs result in minimal fibular rotation, double suture button constructs minimize fibular translation. This review may serve as a guide for clinicians when approaching these injuries.